Computed tomographic evaluation of depressed skull fractures and associated intracranial injury

Compelling evidence for discretionary brain computed tomographic imaging in those patients with mild cognitive impairment after blunt trauma

OBJECTIVE

To identify computed tomographic-detected intracranial hemorrhage (CTIH) risk factors and outcome in mild cognitive impairment (MCI) blunt trauma patients.

METHODS

In 2,587 consecutive patients, 251 (9.7%) had CTIH.

RESULTS

Analysis is on 2,252 direct transports with 163 CTIH, because transfers were different (7.2 vs. 26.3%, p < 0.0001). CTIH rates for patients age 14-60 and > 60 years were 6.3 and 15.9%, p = 0.001. In those 14-60 years (n = 2,032), CTIH (n = 128) was independently related to arrival Glasgow Coma Scale (GCS) score and cranial soft tissue injury (CSTI) (p = 0.0001). [table: see text] Craniotomy was < or = 0.6% in each group except GCS score of 13 with CSTI, 7.4%. Of those with CTIH, 98.4% survived. Of those at low risk (GCS score of 14 without CSTI and GCS score of 15), 1,504 had no CTIH. Of these, 64.4% were available for serial cognitive evaluation (noncranial injuries mandated hospitalization; tracheal intubation was not required). In those > 60 years (n = 220), CTIH (n = 35) was independently related to GCS and CSTI (p = 0.003). CTIH for GCS score of 15 without CSTI was 5.8%, but > or = 16% for others. One craniotomy was required. Of those with CTIH, 91.4% survived.

CONCLUSIONS

In mild cognitive impairment patients triaged directly to a Level I trauma center, age, arrival GCS score, and cranial soft tissue injury are risk factors for CT-detected intracranial hemorrhage. Neurologic deterioration and death are infrequent. These data strongly suggest that observation and discretionary brain CT imaging are a rational approach for blunt-injury mild cognitive impairment.